ACR: Rheumatoid Arthritis Comparable to Diabetes for Heart Risk

Action Points

Explain to interested patients that managing cardiovascular risks may be as important for patients with rheumatoid arthritis as for those with diabetes.

Note that these studies were published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

SAN FRANCISCO, Oct. 28 -- Rheumatoid arthritis independently raises the risks of cardiovascular disease and heart attacks to the level of diabetes, two research groups reported here.

In one population-based study, MI rates were 2.3-fold higher among RA patients and remained significantly elevated after controlling for traditional risk factors (P<0.001), found Christopher J. Edwards, M.D., of Southampton General Hospital in Southampton, England, and colleagues.

In a separate prospective study, RA was as strong a predictor of cardiovascular disease as was diabetes with odds ratios of 2.31 and 2.28, respectively, after full adjustment for traditional risk factors, found Michael T. Nurmohamed, M.D., Ph.D., of the VU University Medical Center in Amsterdam, and colleagues.

These findings presented at the American College of Rheumatology meeting may help explain what is driving the early mortality and increased occurrence of ischemic heart disease seen in rheumatoid arthritis, Dr. Edwards said.

The results also add impetus to improving cardiovascular care for this population, Dr. Nurmohamed said.

In diabetes, added attention to cardiovascular health has already paid off, he noted. But "in rheumatoid arthritis we're just now starting to give better cardiovascular care to our patients."

Dr. Nurmohamed's group compared cardiovascular findings from the prospective CARRE study of 353 RA patients ages 50 to 75 against findings from the Dutch HOORN cohort study of 631 individuals the same age in the general population.

They found that prevalence of coronary artery disease was highest among RA patients at 7.8% compared with 5.7% among diabetes patients in the HOORN study and 3.9% among controls.

Incidence rates were likewise significantly elevated among RA patients (3.3% per year versus 1.5% in the general population).

Incident cardiovascular events were at least as common with RA as with diabetes in the fully adjusted model compared with general population controls. The relative risk ratios were:

Dr. Edwards' group likewise found about two-fold MI risk among RA patients using the British national database of primary care records from 1987 through 2002.

Incidence of MI among the 34,364 RA patients was 6.49 compared with 2.96 per 1,000 person-years among the 103,089 age-, sex-, and general practitioner-matched controls.

MI was 2.23-fold more common with RA in the univariate analysis but remained a strong predictor with incidence rate ratios of 2.08 and 2.09 after full adjustment for traditional risk factors, including use of antihypertensive and lipid lowering drugs (all P<0.001).

Diabetes tended to be a stronger predictor in the univariate model (IRR 3.79, P<0.001 versus controls).

Although these effects lost significance after controlling for other factors, other studies have also generally shown higher risk of cardiovascular disease with prednisolone, Dr. Edwards said.

"If you're using excessive amounts of prednisolone for too long a period of time, then that would be a concern," he said, "because there's a good chance that by pushing up blood pressure and worsening lipid profiles you could increase the likelihood of MI in a group of individuals who are already at increased risk."

But the evidence is evolving in this area, with some more recent studies showing optimized doses when the diagnosis is right could actually reduce heart disease risk, Dr. Edwards noted.

He presented evidence-based recommendations from a European League Against Rheumatism (EULAR) taskforce, which included the following:

Adequate control of rheumatic disease activity (grade B)

Annual cardiovascular risk assessment for all patients with inflammatory arthritis to be repeated when treatment changes (grade C)

Multiply cardiovascular risk score by a factor of 1.5 when arthritis duration is longer than 10 years and when patients are seropositive or have extrarticular manifestations (grade C)

Statins and ACE-inhibitors as the preferred treatment options (grade C)

Use of lowest corticosteroid doses possible (grade C)

No primary prevention with COXIBs or NSAIDs (grade C)

While both studies were done in European settings, Dr. Nurmohamed said the findings will likely be just as useful in the United States.

Although primary prevention with aspirin and other antiplatelet medications is recommended by the American Diabetes Association for diabetes patients, he cautioned that "there is no evidence" and recommended against the strategy for RA patients.

Both research groups reported no conflicts of interest.

Reviewed by Zalman S. Agus, MD Emeritus Professor University of Pennsylvania School of Medicine

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